Volume 209 - Issue 3
Tackling the worsening epidemic of Buruli ulcer in Australia in an information void: time for an urgent scientific response
Authors: Petra Zimmermann, Adam Finn and Nigel Curtis
Med J Aust 2018; 209 (3): 142. || doi: 10.5694/mja18.00502
Published online: 6 August 2018
Published online: 6 August 2018
To the Editor:
A recent article by O’Brien and colleagues1 highlights the worsening epidemic of Buruli ulcer in Australia. The steep rise in both the incidence and severity of the disease is associated with estimated health care costs of over $2.5 million per year in Victoria.1
The increase in Buruli ulcer cases in Australia parallels the increase in non-tuberculous mycobacterial (NTM) infections, especially lymphadenitis and Buruli ulcer, reported worldwide. Although this rise might be partly attributable to improved awareness and diagnostic methods, it might also be related to the discontinuation of universal bacillus Calmette–Guérin (BCG) vaccination in settings where the rate of tuberculosis has declined. Routine vaccination with BCG through the school program was discontinued in Victoria in the mid-1980s.
The live-attenuated strain of Mycobacterium bovis contained in BCG vaccine shares epitopes with NTM, which makes cross-protection plausible. Our recently published meta-analysis indicates that BCG vaccination has a protective effect against NTM.2 In particular, two randomised controlled trials provide strong evidence for protection against Mycobacterium ulcerans.3,4 However, immunity might only be short lived, as the highest protection was observed in the first year after vaccination. Nevertheless, studies also report that compared with BCG-naive individuals, those who have received the BCG vaccine have smaller skin lesions,4 a shorter duration to healing5 and protection against severe forms of Buruli ulcer with multiple skin lesions.6
Buruli ulcer is a serious condition, which, despite prolonged antibiotic treatment and surgical intervention, can lead to complications such as osteomyelitis and other crippling sequelae. In light of the worsening epidemic, the protective effect of BCG vaccination should not be overlooked.
Competing interests
No relevant disclosures.
References
- O’Brien DP, Athan E, Blasdell K, De Barro P. Tackling the worsening epidemic of Buruli ulcer in Australia in an information void: time for an urgent scientific response. Med J Aust 2018; 208: 287-289.
- Zimmermann P, Finn A, Curtis N. Does BCG vaccination protect against non-tuberculous mycobacterial infection? A systematic review and meta-analysis. J Infect Dis 2018. doi: 10.1093/infdis/jiy207. [Epub ahead of print].
- Bradley DJ, Hutt MSR, Kiryabwire JWM, et al. BCG vaccination against mycobacterium ulcerans infection (Buruli ulcer). First results of a trial in Uganda. Lancet 1969; 1: 111-115.
- Smith PG, Revill WD, Lukwago E, Rykushin YP. The protective effect of BCG against Mycobacterium ulcerans disease: a controlled trial in an endemic area of Uganda. Trans R Soc Trop Med Hyg 1976; 70: 449-457.
- Amofah GK, Sagoe-Moses C, Adjei-Acquah C, Frimpong EH. Epidemiology of Buruli ulcer in Amansie West district, Ghana. Trans R Soc Trop Med Hyg 1993; 87: 644-645.
- Noeske J, Kuaban C, Rondini S, et al. Buruli ulcer disease in Cameroon rediscovered. Am J Trop Med Hyg 2004; 70: 520-526.